[Heidelberg Milestones Communication (HeiMeKOM) - Experiences, Best Practice Examples and Recommendations from the Final Symposium on January 30 and 31 in 2020]. / Heidelberger Meilenstein Kommunikation (HeiMeKOM) ­ Erfahrungen, Best Practice Beispiele und Empfehlungen aus dem Abschluss-Symposium am 30./31. Januar 2020.

The National Cancer Plan emphasises the importance of medical communication and calls for its integration into medical education and training. In this context, the Milestone Communication Approach meets the communicative challenges in dealing with lung cancer patients. Interprofessional tandems, consisting of doctors and nurses, conduct structured conversations at defined moments with patients and their relatives. The concept aims at shared decision making, continuity in the care of lung cancer patients and the early integration of palliative care. During the symposium on the Heidelberg Milestone Communication in January 2020, recommendations on the care situation of lung cancer patients in advanced stages were developed. In addition, the further adaptability of HeiMeKOM to other settings and hospitals and to other diseases was discussed as well as the possibility of implementing such a concept in standard care. This article presents the experiences, best practice examples and recommendations discussed during the symposium in order to enable their extrapolation to other similarly oriented projects. The long-term goal is to transfer the milestone concept to other hospital, primarily certified lung cancer centers, and to ensure permanent funding. For further dissemination of the concept and, above all, to have it established in standard care, health policy awareness and support are required in addition to the integration of the concept in competence catalogues of continuing medical and nursing education.

Surveillance and care for confirmed and suspected patients with COVID-19 in general practice (CovidCare): study protocol for an observational trial.

BACKGROUND: A SARS-CoV-2 infection can lead from asymptomatic through to critical disease in a dynamic and unpredictable course within a few days. The challenge in outpatient monitoring the highly contagious COVID-19 disease during the ongoing pandemic is to filter severe courses followed by admission to hospital with the aim of preventing an overburdening of clinics. However, little is known of the effect of risk factors on the course of the infection of outpatient patients. To support general practices in managing high risk patients, we designed a COVID-19 surveillance and care tool (CovidCare). It includes an initial assessment of yet known risk factors and symptoms and a continuous telephone monitoring of signs and symptoms. This study aims to investigate the effects of different risk factors on the course of the COVID-19 disease, utilisation of different health care services and to gain insights into the utilisation of CovidCare in general practices. METHODS: We will conduct a multi-centered prospective, longitudinal non-controlled observational trial of COVID-19 patients in general practices. Overall, 700 GPs who participate in general-practice centered care by the AOK Baden-Württemberg (large German sickness fund) are eligible and will be invited for study participation, including adult, outpatient COVID-19 patients (or urgent suspicion and ≥ 50 years) with at least one additional known risk factor, who participate in general-practice centered care. The primary outcome is hospitalisation due to COVID-19. Secondary outcomes are diagnosis of pneumonia, utilisation of palliative care, mortality rate, anxiety and identification of predictive risk factors. Quantitative data analysis will focus on valid descriptive figures and mixed regression models. The accompanying process evaluation is based on interviews and questionnaires from general practice staff and patients. The analysis of the process evaluation is descriptive and explorative. DISCUSSION: The use of the COVID-19 surveillance and care tool is expected to encourage the provision of structured quality of care during the ongoing pandemic. This trial will provide an understanding of the COVID-19-disease and the effect of several risk factors on the course of the disease and health care utilisation. The results can be used for a better management of the COVID-19 pandemic and its consequences. TRIAL REGISTRATION: German Clinical Trials Register DRKS00022054 .

Early integration of palliative care for outpatients with advanced cancer in general practice: how is the situation?-a cohort study.

BACKGROUND: Compared with standard care alone, early integration of specialist palliative care in the treatment of patients with advanced cancer offers significant benefit with respect of symptom control, healthrelated quality of life and survival. The early integration of specialist palliative care means that patients receive palliative care concurrent with, or shortly after, the diagnosis of advanced cancer. METHODS: Using data from 2015 compiled from a large German statutory health insurance company (AOK Baden-Wuerttemberg) which insures 3.87 million people, we evaluated how many patients were identified with advanced metastatic cancer and at what point in time, if ever, general practitioners referred them to a specialist palliative home care team. The data were collected exclusively from general practices in the BadenWürttemberg province of Germany. Patients with advanced cancer where identified using all ICD-10 codes for cancer and the ICD-10 codes for metastases. Patients receiving care from a palliative care team were identified using the codes 01425 or 01426 of the German medical fee schedule. RESULTS: We identified 3,535 patients diagnosed with advanced cancer as having palliative care needs. 669 (18.9%) of these were referred to a specialist home care team. Of these, 302 (45.1%) where referred to a palliative care team on the day they were diagnosed but 367 (54.9%) were referred only at a later point in time. Two hundred and six (30.8%) patients had a delayed referral after 8 weeks or more and 153 (22.9%) after more than 12 weeks. CONCLUSIONS: Over half of the cancer patients in general practice who are referred for specialist palliative care are done so very late. General practitioners appear to need encouragement for the early integration of palliative care for patients with advanced cancer and to initiate early referrals to palliative care teams.

Identifying Palliative Patients in General Practice: Focusing on the Place of Death and the Vital Role of Specialized Home Palliative Care: An Observational Study.

Objectives: Specialist palliative care was introduced into the German health care system for patients at the end of life. The primary objective of this study was to assess whether the provision of specialist home palliative care (SHPC) for outpatients increased the likelihood of patients dying at home. Methods: We studied data collected in 2015 from a German statutory health insurance company covering 3.872 million people. We evaluated how many patients were identified as needing palliative care and whether these patients were able to stay at home until death. The data were ascertained from general practices in Baden-Wuerttemberg, a part of Germany. Palliative care patients were identified using the International Classification of Diseases (ICD)-10 code Z51.5 or the assigned medical billing code of the German fee schedule. Patients receiving care from an SHPC team were identified using the billing codes 01425 or 01426. Adjusted odds ratios were calculated for the place of death with multivariable logistic regression. Results: We found 21,190 (0.55%) palliative patients in the whole population. Of these, 19,507 (92.05%) patients received general palliative care and 1683 (7.95%) patients received specialist palliative care. Mortality rate across all patients was 1.08% (41,800) and mortality rate of palliative patients was 44.08% (9494). In total, 19,833 (47.5%) of the general population died in hospitals, as opposed to only 2208 (23.2%) among palliative patients. Further analysis revealed that of those palliative patients receiving SHPC, 160 (13.3%) died in hospitals as opposed to 2048 (24.7%) of those receiving general care. The probability of dying at home increases already with the label "palliative patient" and gets stronger if care is provided by a specialist palliative care team. Conclusion: Most palliative patients are able to die at home. Palliative care teams are responsible for a small part of these patients. Despite the high symptom burden in this group, most are able to die at home.

How to ensure basic competencies in end of life care - a mixed methods study with post-graduate trainees in primary care in Germany.

BACKGROUND: Providing end of life care (EoLC) is an important aspect of primary care, which reduces the risk of hospital admission for most patients. However, general practitioners (GPs) seem to have low confidence in their ability to provide EoLC. Little is known about an adequate volume and kind of training in EoLC among GP trainees. METHODS: We performed a before-after comparison in all post-graduate GP trainees who were registered in the vocational training program (KWBW VerbundweiterbildungPLUS). They were offered participation within a two-day seminar focussing on palliative care in 2017. Those who attended the seminar (intervention group I) completed a paper-based questionnaire directly before the intervention (T1) and 6 months after (T2). None-attendees (group C) were also asked to fill out the questionnaire once. The questionnaire covered previous experiences in palliative care, self-assessment of competencies in EoLC in the organisation of patient care as well as in control of symptoms, attitudes towards death and caring for dying patients and questions about GPs' role in EoLC. RESULTS: In total, 294 GP trainees (I: n = 219; C: n = 75) participated in the study. Of those, more than 90% had previously gained experience in EoLC mainly during vocational training in the hospital rotation. Around a third had previously gained competencies in EoLC in medical school. Between groups I (T1) and C no significant differences were observed in socio-demographic characteristics, pre-existing experience or overall expertise. At T2, 75% of participants of group I declared they have extended their competencies in EoLC after the intervention and 70% classified the intervention as helpful or very helpful. Overall, they rated their competencies significantly higher than at T1 (p < 0.01). In detail, competencies in organisation of EoLC and competencies in handling of symptoms significantly improved (p < 0.01). Due to the intervention, 66% could reflect their attitudes towards dying, death and grief and 18% changed their attitudes. Group I highlighted palliative care as one of GPs tasks (Likert 4.47/5, SD 0.75). CONCLUSIONS: The intervention fostered personal competencies, understanding and self-confidence in EoLC among GP trainees. This is crucial for the aim to broadly provide EoLC.

Challenges in supporting lay carers of patients at the end of life: results from focus group discussions with primary healthcare providers.

BACKGROUND: Family caregivers (FCGs) of patients at the end of life (EoL) cared for at home receive support from professional and non-professional care providers. Healthcare providers in general practice play an important role as they coordinate care and establish contacts between the parties concerned. To identify potential intervention targets, this study deals with the challenges healthcare providers in general practice face in EoL care situations including patients, caregivers and networks. METHODS: Focus group discussions with general practice teams in Germany were conducted to identify barriers to and enablers of an optimal support for family caregivers. Focus group discussions were analysed using content analysis. RESULTS: Nineteen providers from 11 general practices took part in 4 focus group discussions. Participants identified challenges in communication with patients, caregivers and within the professional network. Communication with patients and caregivers focused on non-verbal messages, communicating at an appropriate time and perceiving patient and caregiver as a unit of care. Practice teams perceive themselves as an important part of the healthcare network, but also report difficulties in communication and cooperation with other healthcare providers. CONCLUSION: Healthcare providers in general practice identified relational challenges in daily primary palliative care with potential implications for EoL care. Communication and collaboration with patients, caregivers and among healthcare providers give opportunities for improving palliative care with a focus on the patient-caregiver dyad. It is insufficient to demand a (professional) support network; existing structures need to be recognized and included into the care.

[Five-year experience with Train-the-Trainer courses for general practice trainers - a qualitative and quantitative analysis]. / Fünf Jahre Train-the-Trainer-Kurs für weiterbildungsbefugte Hausärzte - qualitativ-quantitative Analyse der Begleitevaluation.

BACKGROUND: A Train-The-Trainer course (TTT course) for general practice trainers was developed as part of the program Verbundweiterbildungplus Baden-Württemberg. The course included aspects of training such as organizational and legal knowledge as well as didactic skills for trainers in 9.5 teaching units (45minutes each). The present article analyzes the evaluation of the course and considers possible future developments for TTT courses in Germany. METHODS: An evaluation tool was used covering aspects such as information, relevance for daily work, opportunities for participant engagement in the seminars and working environment as well as didactic competencies among teachers. Within five years, 256 trainers participated in a TTT course and received an evaluation sheet. Data were analyzed descriptively. RESULTS: 249 evaluation sheets were included (response rate 97 %). Overall, the participants were (very) satisfied with the course in general, its organization, the exchange with colleagues and the teaching units. The participants used the free text mode to give positive feedback; in particular, teaching units in organizational and legal regulations as well as practical feedback training to strengthen professionalism were evaluated positively. Suggestions for improvements included follow-up courses or a deepening of understanding of course contents. CONCLUSION: The participants gave a very positive overall rating and claimed to have benefited from the course contents. Future projects should address further qualifications of general practice trainers and facilitate the exchange with colleagues on an ongoing basis.

Correlation between patient quality of life in palliative care and burden of their family caregivers: a prospective observational cohort study.

BACKGROUND: Family caregivers play a key role in palliative care at home, and understanding the interdependencies in the constellation of patient, family caregivers and service providers is important. As few longitudinal studies have examined the influence of patient quality of life (QoL) in palliative care on burden of family caregivers, the aim of this study was to identify correlations between changing patient QoL and changing burden of family caregivers that need consideration in patient management. METHODS: Palliative patients with cancer in primary care evaluated their QoL (Quality of Life Questionnaire Core 15 Palliative Care, QLQ-C15-PAL). They were assessed monthly for an interval of 6 months or until death of the patient. Family caregivers reported the burden they perceived while supporting the patient (Short form of the Burden Scale for Family Caregivers, BSFC). Longitudinal data were analysed for all patients with at least 3 available assessments, considering the most recent data for participants with more than 3 assessments. Changes in patient QoL were analysed using the Friedman test. In a stepwise regression analysis, influences of change in patient QoL on changing caregiver burden were investigated. RESULTS: One hundred patients (63 men, 37 women; average age: 68 years) were enrolled in the study. The most common primary diagnoses were colon, lung or breast cancer. In 58 cases, assessments were available from both patients and caregivers. Patients reported overall quality of life increasing towards end of life, although reporting that physical functioning deteriorated. Symptoms of pain and fatigue bothered patients most. Caregiver burden was moderate and on average did not change over time. In a stepwise regression model, the difference in emotional functioning and the difference in dyspnoea showed an influence on the development of caregiver burden (explained variance of 19.3%). CONCLUSIONS: Patients' dyspnoea, feelings of depression and anxiety impacted on the perceived burden of family caregivers, but are manageable symptoms. Our results corroborate the need of regular assessment of patients' needs taking into account caregiver burden. In this way, general practice teams can intervene early and may more likely meet patients' needs in the end of life care process. TRIAL REGISTRATION: Current Controlled Trials ISRCTN78021852, assigned on 04/04/2007.

[Integrated Peer Teaching of Communication and Clinical Skills: How to Train Student Tutors?]. / Integriertes Peer Teaching klinischer und kommunikativer Kompetenzen: Wie bereiten wir studentische Tutoren darauf vor?

AIM: This paper describes the theory-based development of a standardized training model for peer tutors. The aim is to qualify tutors to teach communication skills integrated with practical clinical skills, to medical students in the pre-clinical curriculum. As a result, students are encouraged to form a basic understanding of the biopsychosocial model of diseases early in their studies. METHOD: The training model's design is based on the Kern model for curriculum development as adapted by McLean et al., who outlined the following steps: planning, implementation, and evaluation/feedback. Our focus is on development, review of feasibility, and evaluation as measured by the subjectively perceived effectiveness of the implemented training model. 2 target groups were considered: the peer tutors and the student tutees. RESULTS: In 2009, a 3-step training model consisting of 12 units was developed, based on the theory of patient-centered communication and the biopsychosocial model. The training was rated very positively on a 5-point Likert scale by all tutors at 2 points in time: t1 (directly after training) and t2 (after conducting 2 tutorials) (t1: M=1.67; SD=±0.86; t2: M=1.75; SD=±0.71). On a 6-point Likert scale, the tutees also evaluated their communication and clinical skills as being significantly better after completing the 10 tutorials (t2: scale for interaction and communication: M=4.81; SD: 1.09; scale for clinical examination: M=4.99; SD: 0.85) than before the tutorials (t0: scale for communication and interaction: M=3.18; SD=1.15; scale for clinical examination: M=2.88; SD: 1.09). CONCLUSIONS: By implementing a standardized tutor training model, one can qualify peer tutors to teach communication skills integrated with practical clinical skills during the pre-clinical phase. Practice teaching of the curricular material via role playing, tutorial simulation and an extensive feedback session, along with the definition of clinical standards for recording case histories and performing examinations, have proven themselves to be core elements of effective tutor training.

Long-term opioid use in non-cancer pain.

BACKGROUND: The long-term use of opioid analgesic drugs to treat chronic non-cancer pain (CNCP) is a major component of pain pharmacotherapy. The interpretation of the evidence concerning its efficacy and risks is currently debated. METHODS: An interdisciplinary evidence- and consensus-based S3 guideline was updated on the basis of a systematic literature search (CENTRAL, Medline, and Scopus databases, from October 2008 to October 2013); meta-analyses of randomized controlled trials (≥ 4 weeks); and a consensus procedure, as specified by the AWMF regulations, including 22 medical and psychological societies and 2 patient self-help organizations. RESULTS: 119 publications were used to update the guideline, and 6 systematic reviews with meta-analyses were performed. A nominal group process was used to formulate recommendations concerning the indications and contraindications for the treatment of CNCP with opioid analgesics and the manner in which such treatments should be carried out. Opioid analgesics are an option for the short-term treatment (4-12 weeks) of chronic pain due to osteoarthritis (pain intensity, standardized mean difference [SMD]: -0.22 and -0.26), diabetic polyneuropathy (SMD -0.74), post-herpetic neuralgia (SMD -0.58), and chronic low back pain (SMD: -0.29 and -0.74). Long-term opioid treatment (≥ 26 weeks) for these diseases benefits only about 25% of patients. For other conditions, either short- or long-term treatment with opioid analgesics should be considered an individual therapeutic trial. Opioid treatment for pain is contraindicated by primary headaches and by any functional or mental disorder of which pain is a leading manifestation. CONCLUSION: To minimize the risks of opioid analgesic treatment, physicians must be aware of its contraindications and must regularly reassess its efficacy and side effects. Pharmacotherapy should be combined with other types of treatment.

Palliative patients cared for at home by PAMINO-trained and other GPs - health-related quality of life as measured by QLQ-C15-PAL and POS.

BACKGROUND: To maintain patients' quality of life is one of the major goals in palliative home care provided by general practitioners (GPs). GPs need adequate training to care for palliative patients. The paper seeks to evaluate whether a specific training in Germany (PAMINO) has any improving impact on the care of palliative patients and their health-related quality of life. METHODS: From September 2007 until June 2009, GPs and their palliative care patients with cancer participated in a study to evaluate palliative courses for GPs offered by a regional palliative care initiative (PAMINO). For a period of six months at most or until death, patients were asked monthly to judge their quality of life on the Quality of Life Questionnaire Core 15 Palliative (QLQ-C15-PAL) of the European Organization for Research and Treatment of Cancer (EORTC) and on the Palliative Care Outcome Scale (POS). The 'Overall quality of life' scale of the QLQ-C15-PAL takes values between 0 and 100 with higher values indicating a higher quality of life. The POS sum scale takes values between 0 and 40 with higher values indicating worse care outcomes. Patients cared for by PAMINO-trained GPs and patients cared for by other GPs (control group) are compared using t-tests for differences in group means. RESULTS: One hundred patients participated in the study; 96 patients filled out the questionnaires at least once. On the QLQ-C15-PAL, mean quality of life of the patient groups of PAMINO-trained and other GPs were 37.7 (SD = 25.5) and 39.4 (SD = 26.3) (p = .76), respectively. On the POS, respective mean values of 13.6 (SD = 5.8) and 12.0 (SD = 6.5) (p = .26) were given. Patients cared for by a PAMINO-trained GP did not report better quality of life and care outcomes than patients cared for by other general practitioners. CONCLUSIONS: Patients cared for by PAMINO-trained and other GPs in our study did not report differences in quality of life. Quality of life and care outcomes of all patients were better than of palliative patients in institutional or specialized care, emphasizing the ability of GPs to provide adequate care for these vulnerable patients. However, conclusions need to be drawn cautiously since the study had a small sample size. TRIAL REGISTRATION: Current Controlled Trials ISRCTN78021852.

Varicose veins are a risk factor for deep venous thrombosis in general practice patients.

BACKGROUND: The role of varicose veins (VV) as a risk factor for development of deep venous thrombosis (DVT) is still controversial. The aim of this study in primary care was to determine the impact of varicosity as a potential risk factor for developing DVT. PATIENTS AND METHODS: During the observation period between 01-Jan-2008 and 01-Jan-2011, all cases with VV (ICD code I83.9) and DVT (ICD codes I80.1 - I80.9) were identified out of the CONTENT primary care register (Heidelberg, Germany). The exposure of VV and DVT was based solely on ICD coding without regarding the accuracy of the diagnosis. The covariates age, gender, surgery, hospitalization, congestive heart failure, malignancy, pregnancy, hormonal therapy, and respiratory infection were extracted for each patient. Multivariate binary logistic regression was performed in order to assess potential risk factors for DVT. The SAS procedure "PROC GENMOD" (SAS version 9.2, 64-bit) was parameterised accordingly. A potential cluster effect (patients within practices) was regarded in the regression model. RESULTS: There were 132 out of 2,357 (5.6 %) DVT episodes among patients with VV compared to 728 out of 80,588 (0.9 %) in the patient cohort without VV (p < 0.0001). An increased risk of DVT was associated with previous DVT (adjusted odds ratio (OR): 9.07, 95 % confidence interval (CI): 7.78 - 10.91), VV (OR 7.33 [CI 6.14 - 8.74]), hospitalization during the last 6 months (OR 1.69 [CI 1.29 - 2.22]), malignancy (OR 1.55 [CI 1.19 - 2.02]), and age (OR 1.02 [CI 1.01 - 1.03]). CONCLUSIONS: There are strong associations between VV and DVT in a general practice population with documented VV. Special medical attention is required for patients with VV, a history of previous venous thromboembolism, comorbid malignancy, and recent hospital discharge, particularly those with a combination of these factors.

Train the Trainer for general practice trainer - a report of the pilot within the programme Verbundweiterbildung plus.

BACKGROUND: Since 2008 the Verbundweiterbildung(plus) programme of the Competence Centre General Practice Baden-Wuerttemberg offers continual improvement with regards to content and structure of general practice training. The programme uses the didactical concept of the CanMEDs competencies, which were developed in Canada, as a postgraduate medical training framework. Train the trainer (TTT)-programmes are an additional important element of these contentual optimisations of postgraduate training. Within this article we describe the conception and evaluation of the first TTT-workshop within the programme Verbundweiterbildung(plus). METHODS: The conception of the first TTT-workshop was influenced by results of a survey of general practitioner (GP) trainers and by experiences with teaching GP trainers involved in medical undergraduate teaching. A questionnaire was designed to get a self-assessment about organisational and didactic aspects oriented on the CanMEDs competencies of postgraduate medical training. In addition, the workshop was evaluated by the participants. RESULTS: The workshop lasted 12 teaching units and included the following elements: introduction into the CanMEDs competencies, feedback training, fault management, legal and organisational aspects of post graduate training. From the 29 participating trainers 76% were male and on average 57 years old. The evaluation showed a good to very good acceptance of the workshop. Initial self-rating showed the need of improving in the fields of determining learning objectives, providing formative feedback and incorporation of a trainee. Most trainers rated themselves as very good in procure CanMEDs competencies with the exclusion of the competencies "Manager" and "Scholar". CONCLUSION: A TTT-programme is an important method to improve GP training which has not been used in Germany so far. Such a GP TTT-programme should highlight especially training in providing feedback and teaching in management aspects. Results of this article add information that can be used for developing TTT-programmes also in other specialties.

PalliPA: How can general practices support caregivers of patients at their end of life in a home-care setting? A study protocol.

BACKGROUND: The care of patients with a life-threatening, progressive and far advanced illness in a home-care setting requires appropriate individual care and requires the active support of family caregivers. General practice teams are usually the primary care givers and first contact and are best placed to offer support to family caregivers and to recognise and respond to the burden of care giving on family members. The aim of this project is to develop a best practice model for engaging with and supporting family caregivers. FINDINGS: The project is framed as an exploratory trial for a subsequent implementation study, covering phases 0, I and II of the MRC (Medical Research Council) framework for development, design and evaluation of complex interventions. The project is a multi-method procedure and has two phases. In the first phase, which has already been completed, we used a reflective practice procedure where general practice teams were asked about how they currently deal with family caregivers. In the second phase, a participatory action research approach aims to improve identification and response to when support is necessary for family caregivers. Ten participating general practice teams each enrol 40 eligible patients and their family caregiver, to identify structures and tools feasible for use in their practice. Standardised self-reported questionnaires (Burden Scale for Family Caregivers and Quality of Life Questionnaire Core 15 Palliative) are being applied at study inclusion (prior to or during the implementation period) and after 6 and 12 months to explore implementation effects. Qualitative assessment of general practice teams' experiences will be triangulated with the quantitative evaluation of the implementation. DISCUSSION: This two-step approach, which is appropriate to primary palliative care in the German health care context, will enable general practice teams to develop feasible, acceptable and successful strategies for the implementation of best practice to successfully support family caregivers of patients at the end of life.

Lowering missing item values in quality-of-life questionnaires: an interventional study.

OBJECTIVE: Missing item values (MIV) often occur in quality-of-life (QoL) questionnaires. This study aimed to examine whether the use of introductory exemplary questions reduces the number of MIV and what patient-related factors influence effectiveness of such a QoL form training. METHODS: In a randomized controlled study in ten primary care practice settings, a total of 215 consecutively recruited patients with at least one chronic disease were requested to complete the Medical Outcomes Study 36 Items Short Form (SF-36) questionnaire, German version 1.0. Prior to filling out the QoL form, a sample of randomly selected patients answered three simple written questions similar in wording and appearance to the original SF-36 questionnaire. RESULTS: In total, 126 (58.6%) patients completed the SF-36 questionnaire without MIV. Despite MIV the forms of 46 (21.4%) patients were still computable, i.e., scoring of scales was possible after use of the standardized SF-36 imputation algorithm. After the imputation procedure, MIV significantly hampered generating computable sum scales in 29 (26.6%) of the control group and 14 (13.2%) of the interventional group (P < 0.05). A univariate analysis suggested no evidence that the number of MIV was reduced by the intervention. However, intervention led to a significant decrease of MIV in males but not in females. The education status affected the number of missing data independent of intervention. CONCLUSION: This cross-sectional study showed that the prior use of three self-created questions similar in wording and appearance to the SF-36 questionnaire significantly reduces MIV in male patients. School qualification of QoL respondents inversely correlated with the number of questionnaire MIV, but independent of education status all subjects did benefit from the QoL form training.

How do primary care doctors deal with uncertainty in making diagnostic decisions? The development of the 'Dealing with Uncertainty Questionnaire' (DUQ).

RATIONALE, AIMS AND OBJECTIVES: Diagnostic uncertainty plays an important role in primary care. Nevertheless, the practical way how general practitioners (GPs) deal with uncertainty remains unclear. The purpose was to develop a questionnaire which describes and measures the level of action and active reasoning in dealing with uncertainty. METHODS: Raw items for the 'GP action scale' and 'GP diagnostic reasoning scale' were derived by literature research. The questionnaire was modified by focus group discussion. The final version was administered to 325 GPs. The results of the 'Dealing with uncertainty questionnaire' (DUQ) were compared with the scales of the 'Physician Reaction to Uncertainty' (PRU) questionnaire. PRU measures affective reactions to uncertainty. RESULTS: Item-scale correlation of the 'GP action scale' and 'GP diagnostic reasoning scale' ranged from 0.41 to 0.61 and from 0.31 to 0.53, respectively. Crohnbach's alpha for 'GP action scale' was 0.75 and for 'GP diagnostic reasoning scale' 0.62. The 'GP diagnostic action scale' was significantly positively associated with 'Anxiety due to uncertainty', 'Concern about bad outcomes' and 'Reluctance to disclose mistakes to physicians', scales of PRU. In female doctors, 'Concern about bad outcomes' correlated positively with the 'GP diagnostic reasoning scale' (0.213; P < 0.05). In male doctors, 'Anxiety due to uncertainty' correlated negatively with the 'GP diagnostic reasoning scale' (-0.163; P < 0.05). CONCLUSIONS: Diagnostic reasoning in primary care appears as a complex process using typical primary care inherent 'heuristics'. Affective intolerance against uncertainty correlates with self-rated diagnostic activity. Affective reactions to uncertainty might influence gender-specific reactions to uncertainty in different ways.

Chronic pain in German general practice.

INTRODUCTION: This study evaluates the prevalence of chronic pain, intensity of pain, activity limitation, and pain-related diagnoses in German general practices. METHODS: In 40 general practices, up to 50 consecutive patients presenting to general practitioners (GP) for routine medical consultation were questioned, and those reporting pain that lasted for more than 3 months received a questionnaire referring to intensity of pain and activity limitations. GPs received a questionnaire asking about the duration of treatment and diagnoses. RESULTS: Three hundred forty-six out of 1,860 questioned patients suffered from pain that lasted for more than 3 months (a point prevalence of 18.4% [95% confidence interval 16.7-20.3]). The average degree of pain equaled 5 out of 10 points on a numerical grading scale (NRS); the average degree of activity limitation was 4.8 out of 10. In most cases, the pain was related to musculoskeletal degenerative diseases. CONCLUSION: Chronic pain patients constitute a considerable share of workload in general practice.

[Response judgement - conventional versus new methods]. / Beurteilung des Therapieerfolgs - konventionelle versus neue Methoden.

New ways of evaluating treatment success among thoracic tumour patients are increasingly being used alongside more conventional methods. These new approaches include tumour regression grading, CAD volumetry (computer-assisted volumetry), determination of the tumour density and tumour perfusion as well as the use of positron emission tomography (PET) using 18F-FDG (fluorodeoxyglucose) or other tracers. Increasingly, endpoints that impact directly on the patient's quality of life and tumour-related symptoms are becoming more relevant factors together with the objectively measurable parameters used for assessing treatment response. This contribution describes the potential value of new methods and end-points from the point of view of a pathologist, radiologist, nuclear medicine specialist, radiotherapist, thoracic surgeon, medical and pneumology oncologist, and general practitioner.

The PAMINO-project: evaluating a primary care-based educational program to improve the quality of life of palliative patients.

BACKGROUND: The care of palliative patients challenges the health care system in both quantity and quality. Especially the role of primary care givers needs to be strengthened to provide them with the knowledge and the confidence of applying an appropriate end-of-life care to palliative patients. To improve health care services for palliative patients in primary care, interested physicians in and around Heidelberg, Germany, are enabled to participate in the community-based program 'Palliative Medical Initiative North Baden (PAMINO)' to improve their knowledge in dealing with palliative patients. The impact of this program on patients' health and quality of life remains to be evaluated. METHODS/DESIGN: The evaluation of PAMINO is a non-randomized, controlled study. Out of the group of primary care physicians who took part in the PAMINO program, a sample of 45 physicians and their palliative patients will be compared to a sample of palliative patients of 45 physicians who did not take part in the program. Every four weeks for 6 months or until death, patients, physicians, and the patients' family caregivers in both groups answer questions to therapy strategies, quality of life (QLQ-C15-PAL, POS), pain (VAS), and burden for family caregivers (BSFC). The inclusion of physicians and patients in the study starts in March 2007. DISCUSSION: Although participating physicians value the increase in knowledge they receive from PAMINO, the effects on patients remain unclear. If the evaluation reveals a clear benefit for patients' quality of life, a larger-scale implementation of the program is considered. TRIAL REGISTRATION: The study was registered at 'current controlled trials (CCT)', registration number: ISRCTN78021852.

Quality of life and objective disease criteria in patients with intermittent claudication in general practice.

BACKGROUND: The quality of life (QoL) of patients with chronic diseases is an important decision criterion for medical treatment, especially in primary care settings. It is known that subjective sickness feelings often cannot be correlated with objective disease criteria. OBJECTIVE: The aim of the study was to determine the QoL of patients with intermittent claudication with the arterial morphology, haemodynamic parameters and functional disability of peripheral arterial occlusive disease (PAOD). METHODS: In 150 patients with stable intermittent claudication, the health-related QoL was compared with the angiogram score, the resting Doppler pressure values, and the initial claudication distance (ICD) and absolute claudication distance (ACD) with treadmill exercise. RESULTS: The QoL did not correlate significantly with either the angiogram score or the ankle systolic blood pressure and ankle brachial index. ICD and ACD correlated significantly with the QoL activity subscales of pain, complaints and functional status (P < 0.001). In a multiple regression analysis, ACD and body mass index were the most predictive variables for the QoL. CONCLUSION: The QoL of PAOD patients is independent of the peripheral Doppler pressure and the angiographic severity of the disease. The most important criterion for the QoL is the patient's functional disability.